Republicans’ failure on health care is worse than they realize

President Donald Trump is under the impression that he just repealed the Affordable Care Act, an illusion for which he will receive much welldeserved mockery. The truth, however, is that he and the Republican Congress have made a dramatic impact on the future of American health care, not to mention health-care politics. With every step they take, the arrival of a universal government health insurance system gets closer.

Let's begin here. Tuesday, Trump tweeted:

"Based on the fact that the very unfair and unpopular Individual Mandate has been terminated as part of our Tax Cut Bill, which essentially Repeals (over time) ObamaCare, the Democrats & Republicans will eventually come together and develop a great new HealthCare plan!"

Needless to say, repealing the individual mandate does not repeal the ACA; most of the law's provisions are still in place. Does the president actually believe that Democrats and Republicans are going to come together to pass a healthcare plan? Who knows. Perhaps he has a firm grasp on the politics of the moment but is trying to give Americans hope for a future of bipartisan cooperation. Or perhaps he is as much a fool as he appears. It also might be that he knows full well that he hasn't repealed the ACA, but finds political utility in proclaiming victory when his actual repeal effort was such a spectacular failure.

But as Robert Pear of the New York Times notes, the elimination of the individual mandate has the effect of making the ACA more of a government insurance plan than it was under Barack Obama:

"In short, President Barack Obama's signature domestic achievement is becoming more like what conservatives despise – government-run health care – thanks in part to Republican efforts that are raising premiums for people without government assistance and allowing them to skirt coverage.

"By ending the tax penalty for people who do not have coverage, beginning in 2019, Republicans may hasten the flight of customers who now pay the full cost of their insurance. Among those left behind under the umbrella of the Affordable Care Act would be people of modest means who qualify for Medicaid or receive sizable subsidies for private insurance."

On the whole, that's a bad thing, since premiums will rise even more quickly and more people will be uninsured. But those with low incomes will be getting free or low-cost insurance courtesy of the government, which everyone else will continue to notice. We wind up with a system made up of 1) people who get coverage from the government and are happy with it; 2) people who get coverage from their employers, and like the coverage but don't like the cost; 3) a small number of people who pay the full cost of private coverage, which is increasingly unaffordable; and 4) people who are uninsured and wish they could get on a government plan such as Medicare or Medicaid.

You can imagine an alternate universe in which instead of going hellbent for repeal, Republicans made a decision to embrace some modest fixes to the ACA and expand opportunities for private coverage. Had they done that, the pressure to move to a universal government program might have been sapped. Instead, Republicans failed to kill the ACA but did just enough damage to it to give Democrats the opening to go much further.

And go further they will. Every Democratic presidential candidate in 2020 will present some kind of universal plan, which many of them will call "single payer" (even if none of them are likely to actually be true single payer). The Democratic base has moved to the left on this issue, no longer willing to accept technocratic tweaks to the existing system. And thanks to Republicans, the broader public seems more ready to hear proposals for universal coverage built on government insurance. The more those ideas get debated by mainstream Democratic figures (i.e. not just Sen. Bernie Sanders), the more it seems like a reasonable policy alternative.

Think for a moment about what that 2020 primary debate is going to be like. It will probably resemble 2008, in which the major candidates had very similar plans but disagreed on the details. By the time their debate was over, a rough consensus had been reached, and Obama and the party had a mandate to pursue that version of health-care reform once they took office (or if you like, had no choice but to do it).

In 2020, the candidates will be arguing not about whether we need universal coverage but about exactly how to get it. There may be some advocating "Medicare for all," while others will propose hybrid systems that keep private insurance in place but still greatly expand government's role.

Trump and other Republicans will shout that the Democrats are proposing socialist schemes that will give bureaucrats control of your health care, but whatever shred of credibility they had with the public on this issue has withered away. And they won't be offering any substantive alternative, because as the past year has proved, they're constitutionally incapable of thinking seriously about health care.

That was their political problem as well. Not only couldn't they come up with a reasonable plan to replace the ACA; they couldn't even come up with a political plan to repeal it. They assumed that they could toss around some empty rhetoric about "patientcentered" insurance and the magic of the free market, and no one would notice that they wanted to snatch coverage from tens of millions of Americans. It was doomed from the start.